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11/4/2013

The Submaximal Clinical Exercise Tolerance Test (SXTT) to Establish Safe Exercise Prescription Parameters for Patients

CardiopulmPhysTherJ.2012June23(2):1929.

PMCID:PMC3379719

TheSubmaximalClinicalExerciseToleranceTest(SXTT)toEstablishSafeExercise PrescriptionParametersforPatientswithChronicDiseaseandDisability
EduardGappmaier,PT,PhD
AuthorinformationCopyrightandLicenseinformation

Abstract
Purpose

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To describe how to perform a Submaximal Clinical Exercise Tolerance Test (SXTT) as part of an exercise evaluation in the physical therapy clinic to determine an appropriate exercise prescription and to establish safety of exercise for physical therapy clients.
SummaryofKeyPoints

Physical activity is crucial for general health maintenance. An exercise evaluation includes a comprehensive patient history, physical examination, exercise testing, and exercise prescription. The SXTT provides important clinical data that form the foundation for an effective and safe exercise prescription. Observations obtained during the exercise evaluation will identify at-risk patients who should undergo further medical evaluation before starting an exercise program. Two case examples of SXTTs administered to individuals with multiple sclerosis are presented to demonstrate the application of these principles.
StatementofRecommendations

Due to their unique qualifications, physical therapists shall assume responsibility to design and monitor safe and effective physical activity programs for all clients and especially for individuals with chronic disease and disability. To ensure safety and efficacy of prescribed exercise interventions, physical therapists need to perform an appropriate exercise evaluation including exercise testing before starting their clients on an exercise program. Key Words: exercise evaluation, clinical exercise testing, exercise prescription

INTRODUCTIONANDPURPOSE

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The health benefits of regular physical activity have been widely publicized. On the other hand, many clinical observations indicate that negative physical effects occur with inactivity. According to the 2008 Physical Activity Guidelines for Americans, published by the United States Department of Health and Human Services, adults should perform at least 150 minutes a week of moderate-intensity, or 75 minutes a week of vigorousintensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity.1,2(p vii) Moderate-intensity aerobic physical activity has been defined as 40% to 59% of aerobic capacity reserve and vigorous-intensity activity as 60% to 84% of reserve.2(p55) Healthy, asymptomatic, previously inactive adults may begin moderate-intensity activity safely without the need to consult a health care provider. However, individuals with symptoms, chronic conditions, or disabilities are advised to begin an exercise program after appropriate medical evaluation and with guidance of a health care provider.1,2,3(pp
viii,36,39,43,44)

The American Physical Therapy Association (APTA) enthusiastically endorses the national effort to increase physical activity in all sedentary persons.4 Due to their extensive clinical background, their expertise in exercise physiology and the movement sciences and the physical therapy patient management model with a

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focus on client-centered care, the physical therapist is uniquely positioned to assist people of all ages and abilities to design and monitor safe and effective physical activity programs that help establish life-long habits of physical activity.5,6 Since persons with symptoms, chronic conditions, or disabilities may have limited exercise tolerance and are at increased risk for adverse events associated with physical activity, they require a clinical exercise evaluation to screen for potentially dangerous signs or symptoms of exercise intolerance and to establish safe and appropriate parameters for their exercise prescription. A maximal exercise test or clinical stress test is considered the gold standard to determine maximal exercise capacity as a baseline for exercise prescription and to reveal potential signs and symptoms suggesting myocardial ischemia due to coronary artery disease or other abnormal physiological responses to exercise. These tests however require advanced expertise and equipment. They are associated with a higher risk for complications due to exercise to the point of volitional exhaustion or occurrence of signs or symptoms of cardiovascular compromise and thus may require medical supervision. Standard submaximal exercise tests as described in ACSM's Guidelines for Exercise Testing and Prescription and summarized by Noonan et al7,8 to estimate maximal oxygen uptake are based on several assumptions. One primary assumption is that the maximal heart rate of the individual undergoing the test is similar to a predicted maximal heart rate based on a formula such as 220-age. Such formulae may be applied with caution to healthy individuals as long as one is aware of the significant inter-individual variability (SD=10-12 beats/min) of maximal heart rate.9,10 However, many studies that measured maximal aerobic capacity of persons with a variety of medical conditions such as cardiovascular, metabolic, neurologic or neuromuscular disease found significantly lower maximal heart rates in these patient populations.11,12,13,14,15,16,17,18,19,20 In addition, patients may be on medications that alter heart rate response to exercise.21,22 Another assumption underlying standard submaximal exercise testing is that mechanical efficiency (oxygen consumption at a given work rate) is the same for every person undergoing the test. However, many studies on persons with chronic disease and disability, especially if neuromuscular symptoms are present, have found a significant difference in oxygen cost for a given work rate as compared to healthy controls.23,24,25 Since these assumptions which underlie aerobic capacity predictions based on standard submaximal exercise tests are frequently not met when testing persons with clinical conditions, these tests are usually not appropriate for these populations. The author therefore suggests that a Submaximal Clinical Exercise Tolerance Test (SXTT) is most appropriate in the standard physical therapy clinic to provide baseline data and to determine safe and effective exercise prescription parameters. The purpose of this paper is to describe how an exercise evaluation including a SXTT is performed and to discuss how the resulting data and observations are used to determine an appropriate exercise prescription for clients seen in the physical therapy clinic.

THEEXERCISEEVALUATION

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The objectives of an exercise evaluation include: first, to establish safety for exercise participation, second, to collect the necessary information to write an appropriate exercise prescription and lastly, to collect baseline data for outcome assessment. The components of an exercise evaluation are summarized in Figure 1. It is recommended that clients obtain a referral for an exercise evaluation and prescription from their physician. The physician may note valuable special precautions or considerations on the referral or may recommend prior medical evaluation and testing of high risk patients. The pretest evaluation includes a comprehensive patient history including a complete medical history, medication list, screening for heart disease risk factors, signs and symptoms, and an activity history. This information is best obtained through a comprehensive questionnaire that is completed by the patient before the appointment and then reviewed and clarified if necessary during the patient interview. The physical therapy examination includes a standard musculoskeletal and neurological screening examination as well as a careful cardiovascular and pulmonary screening examination including assessment of resting heart rate and pulse, blood pressure, peripheral vascular status, auscultation of heart and lung sounds, pulse oximetry, and ideally, in patients with increased cardiac risk, a resting ECG. Special tests dependent on the client's specific diagnoses, impairments, and functional limitations may include functional mobility testing, quantitative strength assessment, body composition analysis, pulmonary function testing, health-related quality of life assessment, and disease

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specific assessments such as fatigue assessments for patients with chronic fatigue syndrome, cancer, or multiple sclerosis. While many of these tests may be optional, the minimum information that must be obtained through the patient history and physical examination before conducting the exercise test includes information to satisfy safety and test protocol considerations. Based on the cardiac screening and risk assessment and initial risk stratification following ACSM guidelines,8(p23) the physical therapist determines if it is safe to proceed with an exercise test or if the patient needs to be referred back to the referring physician for further medical evaluation and medical exercise testing. Contraindications to exercise testing are summarized in Table 1. Based on the activity history, musculoskeletal exam, and cardiovascular and pulmonary screening the therapist determines the optimal exercise test mode and the appropriate test protocol. Finally, as should be standard practice today for any physical therapy intervention, an informed consent document is reviewed and discussed with the client and signed before proceeding with the exercise test. Figure 1 Components of an Exercise Evaluation

Table 1 Contraindications to Exercise Testing

TestProtocol

When performing exercise evaluations in the physical therapy clinic, the clinician may face major challenges when considering the optimal exercise protocol. The clinician will encounter a dramatic range of maximal exercise capacities. We sometimes test patients with a peak exercise capacity of as low as 2 METs (ie, person with severe cardiopulmonary disease who barely endures 2 minutes of walking at 1.5 mph) and occasionally test physically active chronic disease patients with mild disability who easily achieve a peak intensity greater than 10 METs. Furthermore, the clinician encounters a great variability in cardiovascular risk profiles. An otherwise healthy client with chronic disease and disabilities may have no significant cardiovascular risk factors while another client may have serious signs and symptoms of cardiovascular, pulmonary, or metabolic disease. In addition the clinician may work with people with chronic disease and a wide range of musculoskeletal or neuromuscular impairments. Conditions such as degenerative joint disease, chronic low back pain, or other musculoskeletal pain syndromes may flare up when subjected to unaccustomed increased physical demands. It should be obvious that no single gold standard clinical exercise testing protocol (ie, Bruce Treadmill Protocol) will meet the demands of such a heterogeneous patient population. This environment requires a highly individualized approach based on either a large menu of standardized facility protocols or a custom design method driven by the pretest assessment of the individual client. The first decision for the examiner to make is to choose the most appropriate mode of exercise for the exercise test. While treadmills and cycle ergometers are most commonly used for clinical exercise testing, these standard exercise devices are frequently not optimal for physical therapy clients if lower extremity impairments or balance problems are limiting their lower extremity work capacity. For such individuals combined arm- and leg ergometry results in higher peak work load, heart rate, and oxygen uptake values.26,27 Due to testing and training specificity issues, it is recommended that the client, if possible, is tested on an exercise device that is consistent with the preferred and available mode of training for the subsequent exercise program. The main requirement for an exercise device used for a progressive testing protocol is a reliable, repeatable, stepwise workload adjustment, ideally with the option to calibrate the power input to assure accuracy. Based on experience and clinical judgment, the evaluator then defines an individualized work rate progression for the respective client that will achieve the desired end-point within an optimal exercise time of 8 to 12 minutes after a low intensity warm-up or chooses an appropriate testing protocol from a series of previously defined facility protocols (see Table 2). When performing a treadmill test on previously inactive, deconditioned clients, the author customizes the protocol to the individual as follows:

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the testing protocol is started with 2 minutes at a slow walking pace to allow accommodation to the treadmill. The treadmill speed may range from 1.0 mph (in rare cases even slower) to 2.5 mph. Over the next few 2-minute stages the walking pace is advanced in 0.5 mph increments to a brisk but comfortable walking speed. During subsequent 2-minute stages, intensity is increased by raising the treadmill grade in 2% increments until criteria for test termination are achieved. This occurs in most cases within the recommended time period of 10 to 20 minutes (including incorporated low-intensity warm-up) with a well-tolerated, comfortable work load progression. When testing on upright or reclined leg cycle ergometers or all-extremity ergometers (ie, Schwinn Airdyne cycle ergometer, NuStep recumbent cross trainer) we select one of 5 workload progressions based on the pretest assessment of the client that usually results in an appropriate test duration with a well-tolerated work load progression (see Table 2). Table 2 Generic Exercise Testing Protocols (Workload in Watts)

Measurements

Measurements obtained during each stage of a SXTT always include workload, heart rate, blood pressure, and ratings of perceived exertion (RPE) and dyspnea. In addition, the client is continuously monitored for abnormal signs or symptoms. When indicated by the client's history and diagnoses, oxygen saturation and the electrocardiogram (ECG) may also be monitored. Peak workload obtained with a maximal exercise test (stress test) is the best indicator of fitness and physical work capacity. When evaluated in relationship to indicators of relative intensity and effort (heart rate, RPE, dyspnea), the peak workload obtained during a SXTT may be used effectively to determine an appropriate intensity for the exercise prescription and may allow for an estimate of physical work capacity (see discussion of test endpoints and exercise prescription below). Heart rate may be reliably monitored through palpation of a radial or carotid pulse or may be obtained through auscultation, however, inexpensive telemetric heart rate monitors are very accurate and reliable as long as electric interference is avoided and are much easier to use. Heart rate may also be obtained with an ECG. Increasingly affordable ECG systems have the advantage of also monitoring heart rhythm and allow for detection of abnormalities suggestive of myocardial dysfunction, both at rest and during exercise, which may warrant further medical evaluation. In his wellness practice, the author has been detecting such rhythm abnormalities during exercise evaluations on average in 1-2 clients (out of 50-60 exercise evaluations) each year. All of these clients have been referred with negative cardiac history and medical clearance for exercise evaluation and prescription by their physicians. Due to these abnormal findings these patients subsequently have been referred back to their referring physicians with the recommendation for further cardiac evaluation. Physical therapists can be at times intimidated by this technology, although essential ECG monitoring skills can easily be acquired through a basic ECG interpretation course offered by many medical facilities, publishers, or online education providers and some practice in the clinic. Blood pressure should be measured at rest in sitting and in the exercise position followed by measurements during each test stage and during recovery. Since most standard automated units are not reliable during exercise, these measurements are best obtained through manual auscultatory methods.28 At the end of each test stage, RPE is measured with a standard Borg8,29,30 or Omni RPE scale31 and dyspnea ratings are obtained with a standardized dyspnea rating scale32 (see Table 3). Before the test, patients are instructed to report any abnormal signs and symptoms they may experience du ring the test. Throughout the test and the recovery period, the patient is carefully observed for signs and symptoms of cardiovascular compromise such as substernal chest pain or other angina symptoms, lightheadedness, pallor, nausea or sudden, unusual sweating or fatigue. Patients with chronic disease and disability also need to be monitored for other clinical symptom changes such as exacerbation of pain in persons with arthritis, symptom modification due to increased core temperature in persons with multiple sclerosis, onset or increases in tremor in persons with neurodegenerative disease, etc.

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Table 3 5-Grade Dyspnea Scale


Testterminationcriteria

One of the most challenging questions when administering a SXTT is when to stop the test. The test is stopped without hesitation if any of the indications for (maximal or symptom-limited) exercise test termination as defined by the ACSM guidelines are met (see Table 4 and 5). In addition, any exercise test intended to be classified as a submaximal exercise test should be stopped when a heart rate of 85% of age-adjusted maximal heart rate (AAMHR) is achieved as per definition of submaximal by ACSM guidelines.8(pg79) However due to their clinical condition or due to the great inter-individual variation of maximal heart rate, the testing subject may reach volitional exhaustion before achieving 85% of AAMHR. This predetermined submaximal exercise test endpoint is thus, in many cases, not relevant. In most cases the SXTT will be terminated by decision of the tester based on predetermined test objectives, the tester's clinical observations and the tester's clinical judgment of the individual's risk of adverse events. In order to determine an appropriate exercise intensity for the exercise prescription, the tester needs an estimate of the subject's maximal physical work capacity. Based on an integrated assessment of both physiological and subjective indicators of subject effort (heart rate, dyspnea level, RPE rating), the experienced tester can usually predict a reliable estimate of the subject's maximal exercise capacity thus meeting one of the primary objectives of the test. This stage in the test will usually be 1-2 levels above the subsequently prescribed, ideal training intensity, so that another objective of the SXTT is met: to demonstrate appropriate acute adaptations to exercise to a level beyond the prescribed training intensity suggesting that the subsequently prescribed exercise parameters will be safe for the client. Thus the SXTT should be terminated, once based on the administrator's subjective appraisal the following two objectives are accomplished: first, an estimate of maximal workload is perceptible and second, the intensity of exercise has been safely progressed beyond apparent moderate to vigorous exercise prescription parameters. The confidence in making this somewhat subjective decision increases with tester experience and the novice test administrator is advised to perform a number of tests under the supervision of a more experienced tester to hone this skill. If this is not possible, then (s)he should proceed initially cautiously with tests on low-risk individuals until confidence in making this decision appropriately is gained. Table 4 General Indications for Stopping an Exercise Test in Low-Risk Adults

Table 5 Indications for Terminating Exercise Testing

Safetyconsiderationsandcontraindications

In order to ensure safety during exercise testing the tester needs to have adequate knowledge of exercise testing and management principles, and understand and follow appropriate exercise testing guidelines as summarized in the ACSMG. Absolute and relative contraindications to exercise testing are listed on Table 1. Contraindications to exercise testing most commonly seen in our clinic are uncontrolled hypertension and previously undetected rhythm abnormalities. The author recommends that the physical therapist require a physician's referral with clearance for exercise participation before proceeding with an exercise evaluation. However, it is important to understand that such a document does not assure the absence of undiagnosed cardiovascular disease and risk of adverse events in response to physiological stress in previously sedentary individuals. These conditions may not be ruled out by a review of the patient's history and a brief physical exam in the physician's office. It is not unusual that a careful pretest screening and physical examination by the physical therapist reveals signs and symptoms of cardiopulmonary disease that would warrant a cardiology evaluation in a client who presents with an appropriate physician's referral. In this case the patient

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is sent back to the referring physician with a note documenting the findings and the suggestion that due to these findings a medically supervised exercise test is recommended by ACSM guidelines before starting an exercise program. Referring physicians usually graciously comply with this proposition. To ensure appropriate responses to potential adverse events during exercise testing, facility emergency procedures need to be clearly defined and basic emergency equipment such as an automated external defibrillator (AED) should be readily available in the testing area.33,34 The tester and support staff should have a minimum of basic cardiac life support (BCLS) certification. A physical therapist who may independently evaluate patients in the high risk category should strongly consider advanced cardiac life support (ACLS) certification.

EXERCISEPRESCRIPTIONANDACTIVITYRECOMMENDATIONS

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The exercise prescription for cardiovascular conditioning includes the following exercise parameters: mode, intensity, duration, and frequency. The exercise prescription needs to be individualized to the respective physical therapy client based on the data obtained in the exercise evaluation and clinical diagnosis, history, current health status, risk profile, exercise history, and the client's goals and preferences. A comprehensive, long-term rehabilitation and wellness program should also include resistance and flexibility exercises and, if indicated, functional mobility and balance training.3 However, a discussion of these areas is beyond the scope of this paper and the discussion in this article will be limited to cardiovascular conditioning or aerobic training. Due to the principle of specificity of exercise, the exercise prescription will be most specific for the mode of exercise that was used during the exercise test. However, exercise parameters may be adapted to other training modes that are appropriate for the respective client. For clients without significant physical impairments and functional limitations, a wide variety of training modes and exercise equipment may be considered. For most of such individuals with low to moderate fitness levels, walking can be used for a simple but effective exercise program35,36,37 or they may use any aerobic exercise equipment as long as the prescribed exercise parameters can be achieved and controlled. As stated earlier, persons with mobility impairments may be able to exercise at higher workloads and thus be able to optimize exercise adaptations and benefits by completing overall higher training volumes when performing combined arm-leg-ergometry. Some may require special equipment accessories or modifications such as leg stabilizers for persons with lower extremity muscle imbalance, full foot plate strap-in pedals for persons with motor control problems and tremors or grip-assist devices for persons with poor grip (see Figures 2 and 3). Figure 2 Recumbent Cross Trainer with Leg Stabilizers and Grip-Assist Device

Figure 3 Custom Pedal with Straps for Combined Arm/Leg Ergometer

Current standards recommend 2.5 to 5 hours of moderate-intensity or 1.25 to 2.5 hours of vigorous-intensity aerobic physical activity per week for adults to achieve and maintain good health/fitness and decrease the risk of diseases related to a sedentary life style. Moderate-intensity aerobic exercise is defined as exercise between 40% and 59% of aerobic capacity reserve that is comparable to 40% to 59% of heart rate reserve (HRR) and vigorous-intensity exercise is considered to be at a training heart rate above 60% HRR (equivalent to > 60% aerobic capacity reserve). In order to appropriately calculate HRR, a person's maximal heart rate needs to be known. However, actual maximal heart rate is not obtained with the SXTT. As discussed earlier, the practice to substitute AAMHR is not appropriate for most clients seen in the physical therapy clinic. However, an appropriate, safe, and effective training intensity can be derived from the measurements and observations obtained during the SXTT. As described in the section above, the experienced tester will have a good sense of the maximal work capacity and maximal heart rate of the subject after observation and analysis

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of the stage-by-stage progression of heart rate and work load during the test as well as physiological and subjective indicators of effort throughout the test and especially during the last stage of the test. Based on this estimate of maximal heart rate (HRmax-estimate) and work load (WLmax-estimate), the tester then determines the intensity prescription for moderate-intensity exercise (40-60% WLmax-estimate or 40-60% of HRR based on HRmax-estimate) for the initial training phase. This exercise intensity may be gradually progressed to vigorous-intensity exercise (60-80% WLmax-esimate or 60-80% of HRR based on HRmaxestimate) if tolerated well throughout the prescribed training duration without undue fatigue or exacerbation of clinical signs or symptoms. Ideally, after completion of the exercise evaluation, the patient is monitored during a subsequent actual exercise training session performed at the prescribed exercise parameters. Depending on the physiological and subjective responses during this practice training session, the exercise prescription can be adjusted if indicated. Guidelines recommend that moderate-intensity exercise is performed for at least 30 minutes at least 5 times per week or vigorous-intensity exercise for at least 20 to 25 minutes at least 3 times per week.2(p vii),8(p 155) For severely deconditioned clients with chronic disease or disabilities, this volume of exercise will most likely be unrealisticat least during the initial conditioning phaseand duration and frequency must be adjusted according to the individual capacity. It is crucial to start with a conservative exercise volume to avoid the development of overuse injuries. It is always easier to increase an overly conservative training load than to be forced to reduce training parameters or even abort the exercise program to allow for recovery from overuse injuries. We usually start new clients with a conservative estimate of exercise duration based on our observations of exertion and subjective fatigue during the SXTT with a recommended frequency of 3 times per week with a rest day between exercise sessions. We tell clients to expect to be moderately tired after the exercise session, but that we expect them to recover within a couple of hours after exercise. If fatigue or any signs of discomfort persist into the next day, we recommend a reduction of exercise parameters. Depending on the specific diagnosis, severity of disease, and level of disability additional special considerations may affect the exercise management of the physical therapy patient. For example, patients with diabetes, especially if dependent on exogenous insulin, will require more frequent glucose monitoring and medication adjustments to compensate for the effects of increased physical activity. Patients with neurodegenerative disease such as multiple sclerosis, may experience symptom modification or a temporary worsening of neurological symptoms in response to an exercise induced increase in core temperature. A discussion of all these special diseasespecific clinical considerations is beyond the scope of this paper and readers are referred to relevant literature such as the ACSM's Exercise Management for Persons with Chronic Disease and Disabilities.11 Finally, the physical therapist needs to remain aware about the potential day-to-day variability in the health status and energy level of persons with chronic disease and disability that requires ongoing reassessment and adaptation of program parameters and education on appropriate self-assessment and self-adjustment by the patient. PATIENT CASE EXAMPLE 1 (see Figure 4 & video online at: http://stream.utah.edu/m/show_grouping.php?g=3f55168646473e2292) Figure 4 Submaximal Clinical Exercise Tolerance Test - Case Example 1 (Jerry)

Jerry is a 59-year-old architect who received a diagnosis of definite relapsing-remitting multiple sclerosis (MS) 8 years ago. Two years ago his diagnostic classification was changed to secondary progressive MS. His EDSS (Expanded Disability Status Scale) score is 7.0, which is defined as unable to walk beyond approximately 5 meters even with aid, essentially restricted to wheelchair; wheels self in standard wheelchair and transfers alone; up and about in wheelchair some 12 hours a day.38 He has been sedentary since time of MS onset and presents with a referral for participation in the University of Utah Multiple Sclerosis Rehabilitation and Wellness Program. His risk factors include overweight, past smoking history, prehypertension, inactivity, and age/gender (older male). He has an otherwise unremarkable medical history except complaints of intermittent palpitations for the past several months. His medication list includes a MS disease-modifying agent, an antispasticity agent, and an antidepressant. None of these medications are

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known to affect the cardiovascular response to exercise. His physical therapy examination reveals normal strength and function in his upper extremities and marked weakness and spasticity in his lower extremities. Based on his clinical impression the tester selects the Schwinn AirDyne arm/leg cycle ergometer as testing mode for the SXTT with an individualized testing protocol starting at 20 Watts with a 20 Watt progression per 2 minute intervals. Due to the patient's risk profile and history of palpitations, the evaluator chooses to monitor the patient's ECG at rest and during exercise. Exercise test data are summarized in Table 6. Jerry's resting heart rate is 68, his resting ECG displays a normal sinus rhythm, his resting blood pressure is 136/76, which is slightly above ideal. During his first test stage, his heart rate increases to 94 and his RPE rating is one (very light; Borg 1-10 scale). His workload is increased to 40 Watts which causes a heart rate increase to 107. His blood pressure is recorded just slightly above resting at 138/78 and his RPE rating is 2 or light. The ECG displays sinus tachycardia without abnormalities. During stage 3 at an intensity of 60 Watts, it becomes obvious that Jerry relies primarily on his arms to maintain the work load. His heart rate increases to 117 and his RPE rating is 4 or somewhat hard. His exercise ECG remains normal. The work load is further increased to 80 Watts for stage 4 of the test. Jerry is obviously exerting significant effort at this intensity, which is also reflected in his RPE rating of 7 or very hard. His heart rate increases to 136 bpm and his blood pressure is recorded at 152/80. Mild to moderate exercise induced dyspnea is evident, rated by the tester as 2 (5-point scale: mild, some difficulty; see Table 3). The ECG continues to show sinus tachycardia without any abnormal waveforms. At this point it is obvious to the tester that Jerry has reached a workload clearly above a reasonable training intensity for his current fitness level. One of the objectives of the SXTT has thus been achieved: since there have been no abnormal signs or symptoms observed throughout the test, the assumption, that Jerry will be safe when exercising at the (lower) intensity, which will be later prescribed for his exercise program, should be warranted. Table 6 Submaximal Clinical Exercise Tolerance Test - Case Example 1 (Jerry)

Based on the tester's integrated assessment of the stage-by-stage observations of the physiological and subjective indicators of subject effort (heart rate, dyspnea level, tester observation of patient effort, RPE rating), the tester also feels quite confident at this point to provide a good estimate of Jerry's maximal exercise capacity thus meeting the second objective of the SXTT. Based on the stage-by-stage observation of subject effort by the tester, consistent with the apparently reasonable RPE ratings given by the subject, the tester has the impression that Jerry would be able to advance to and probably complete the next 2-minute stage at an intensity level of 100 Watts. However, by the end of this stage, he would probably reach volitional fatigue with an RPE rating of 9 or 10 (very, very hard or maximal) and would most likely not be able to continue to the next stage. The tester also estimates that his heart rate, which increased quite linearly during the first 3stages and then increased in slope during stage 4, may have risen another 20-25 bpm during maximal effort. Based on this SXTT, he thus predicts a maximal workload of approximately 100 Watts and a maximal heart rate of approximately 160 bpm. Based on these estimates he determines the following exercise prescription: Target Heart Rate (THR) Range: 105-125 bpm (40-60% HRR based on HRmax-estimate, rounded to nearest 5) with recommended THR: 115 bpm (50% HRR); initial work load: 50 Watts (50% WLmax-estimate). Recommended RPE during training: 3-4 (moderate to somewhat hard), not to exceed 4 (somewhat hard). Initial duration: 15 minutes plus 2-3 minutes warm-up and cool-down, gradually increased as tolerated to 30 minutes. Initial frequency: 3 times per week with at least one rest day between exercise days. Jerry will be closely monitored during his first training session and exercise parameters may be modified if necessary. PATIENT CASE EXAMPLE 2 (see Figure 5 & video online at: http://stream.utah.edu/m/show_grouping.php?g=3f55168646473e2292) Figure 5 Submaximal Clinical Exercise Tolerance Test - Case Example 2 (Linda)

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Linda is a 53-year-old research pharmacologist who received a diagnosis of definite relapsing-remitting MS 24 yrs ago. Several years ago her diagnostic classification was changed to secondary progressive MS. Based on her walking ability her EDSS score is 6.5, which is defined as constant bilateral assistance (canes, crutches, braces) required to walk about 20 meters without resting. 38 She uses a manual wheelchair or electric scooter for energy-efficient ambulation when she leaves her home. In the past she has been moderately active, however, she became more sedentary when she started to use a wheelchair one year ago and now presents with a referral for participation in the University of Utah Multiple Sclerosis Rehabilitation and Wellness Program. Except for MS she has an unremarkable medical history. Her medication list includes a MS diseasemodifying agent, an analgesic drug, and multiple dietary supplements. None of these medications are known to affect the cardiovascular response to exercise. Her medical history and physical examination do not reveal any significant heart disease risk factors, however, she reports a history of PVCs (premature ventricular contractions) on her health history questionnaire. Her physical therapy examination reveals normal strength and function in her upper extremities and marked weakness and mild spasticity in her lower extremities. Based on his clinical impression the tester selects the NuStep Recumbent Cross Trainer as testing mode for the SXTT with an individualized testing protocol starting at 40 Watts with a 10 Watts progression in 2 minute intervals. Due to the patient's self-reported history of PVCs, the tester chooses to monitor the patient's ECG at rest and during exercise. Exercise test data are summarized in Table 7. Linda's resting heart rate is 57, her resting ECG displays a normal sinus rhythm, her resting blood pressure is 108/60. She tolerates the gradual increase in work load from stage 1 to 5 well, which is reflected in her RPE rating that gradually increases to 5 (hard) by stage 5. Her blood pressure response is appropriate with a workload-related increase of the systolic value as expected. Her ECG displays a sinus rhythm without abnormal waveforms or beats. Her heart rate response is blunted from stage 1 to 3, then rises significantly during stage 4 followed again by only a small increase during stage 5, in spite of a considerable increase in effort by the client (see Table 7 and video). At this point in the test Linda is working quite hard, as can be observed by the tester and as reflected by her RPE rating (5, hard). The tester may consider terminating the test at this point. The subject is obviously working at a higher workload/intensity than she will train in the future based on the exercise prescription she will receive later today. One of the objectives of the SXTT has thus been achieved: since there have been no abnormal signs or symptoms observed during the test, the assumption that Linda will be safe when exercising at the (lower) intensity, which will be later prescribed for her exercise program, should be warranted. However, the tester has difficulty interpreting the non-linear, blunted heart rate response of this client. At the end of stage 5, in spite of significant effort, her heart rate is only 103 bpm, which is only 62% of her AAMHR. He decides to continue the test and progress to stage 6 with a work load increase to 90 Watts, which will be very strenuous for Linda. Based on his experience, he anticipates two possible responses which would reveal valuable clinical information important for test interpretation. One possibility may be that the increased sympathetic stimulation associated with the increased effort necessary to produce this workload may result in a further significant increase in heart rate. The other possibility may be the absence of an appropriate heart rate response in spite of the increased effort suggesting chronotropic incompetence, possibly due to an MS-related autonomic neuropathy. As expected, Linda is exerting significant effort at this intensity (see video), which is also reflected by her RPE rating of 7 (very hard). She is relying heavily on her arms to maintain the workload. Mild to moderate exercise induced dyspnea is evident, rated by the tester as 2 (mild, some difficulty). The ECG continues to show a regular sinus rhythm without abnormal waveforms. However, there is no further increase in heart rate, in spite of the valiant effort of the client, who reaches volitional fatigue (my legs gave out) by the end of the 2 minute test stage. This SXTT thus evolved into a maximal exercise test that provides the following information: peak work load = 90 Watts, peak HR = 103 bpm.

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The Submaximal Clinical Exercise Tolerance Test (SXTT) to Establish Safe Exercise Prescription Parameters for Patients

Table 7 Submaximal Clinical Exercise Tolerance Test - Case Example 2 (Linda)

Based on these measurements, the tester determines the following exercise prescription: Target Heart Rate Range: 85-95 bpm (60-80% HRR, rounded to nearest 5; based on his clinical judgment the evaluator determines that the vigorous intensity range is most appropriate in this case); initial work load: 50 Watts (55% peak work load). Recommended RPE during training: 3-4 (moderate to somewhat hard). Initial duration: 15 minutes plus 2-3 minutes warm-up and cool-down, gradually increased as tolerated to 30 minutes. Initial frequency: 3 times per week with at least one rest day between exercise days. Linda will be closely monitored during her first training session and exercise parameters may be modified if necessary. This second real-life case presented by the author was intentionally more complex to demonstrate the importance of clinical judgment and decision making when engaging in the art of exercise testing and prescription. It is also a good example why AAMHR should never be used when prescribing exercise for persons with chronic disease and disability. Without an appropriate exercise evaluation, an uninformed clinician may have prescribed this patient a conservative exercise intensity based on 40% to 60% HRR using AAMHR with a THRR of 101-123 bpm, which would be inappropriate and potentially dangerous.

CONCLUSIONS

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Clinical exercise management requires a highly individualized approach to meet the needs of the diverse patient population seen in physical therapy practice. To ensure safety and efficacy of prescribed exercise interventions, physical therapists need to perform an appropriate exercise evaluation including exercise testing before starting their clients on an exercise program. The Submaximal Clinical Exercise Tolerance Test provides important clinical data that form the foundation for an effective and safe exercise prescription and which may identify at-risk patients who should undergo further medical evaluation before starting an exercise program. While based on sound principles of medical exercise science, clinical exercise management is also an art that requires good clinical decision-making skills as well as experience.

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